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Myth: Hookah smoke is better for you than cigarette smoke and not addictive.

Reality: Hookah smoke of various fruity flavors, tastes and aromas can be even more harmful than cigarette tobacco smoke. Also, hookah smoke contains four times more nicotine (an addictive drug) than cigarette smoke. Some people can become addicted to nicotine after using any form of tobacco just a few times, this includes hookah.

Myth: Smoking hookah is less harmful than cigarettes because the smoke passes through water, which filters out the chemicals and other carcinogens.

Reality: When hookah passes through water at the base of a hookah pipe it cools the smoke, but does not filter any chemicals out of the smoke. This “cooling” process forces a hookah smoker to inhale twice as deeply as a cigarette smoker, which causes chemicals, cancer causing agents, and other harmful elements to penetrate deeper into the lungs. The charcoal that is uses in hookah pipes adds even more carbon monoxide to the higher levels that already exist in this type of tobacco.

Myth: Smoking hookah is fun, and I only do it socially with friends, its not like I do it every day.

Reality: The reality is 45-60 minutes of hookah smoking is the same as chain smoking 15 cigarettes. Even if you are only smoking hookah for an hour, twice a week, it can lead to nicotine addiction. Something also to consider, when you share the mouthpiece with others you are at risk of getting colds, viruses such as herpes simplex one (cold sores), oral bacterial infections and tuberculosis.

E-cigarettes are electronic nicotine-delivery systems (ENDS) that consist of a cartridge containing nicotine and propylene glycol, an atomizer, and a battery (Figure 1). When a user inhales, a pressure-sensitive circuit is activated, which heats the atomizer and vaporizes the liquid as it is brought through the mouthpiece. The vapor consists of a fine mist that does not contain smoke or carbon monoxide and disperses more quickly than traditional cigarette smoke. The act of using ENDS is often called “vaping” and users are termed “vapers.”

The nicotine cartridges used in ENDS come in a variety of flavors, including vanilla, cherry, java, piña colada, and menthol. As the demand rises there are some ENDS stores opening with over 1000 flavors. They are also offered in a myriad of nicotine strengths. When e-cigarettes are inhaled, light-emitting diodes are illuminated. Originally, these lights were red, but now they are often blue or another color to differentiate them from traditional cigarettes.

There is a lot of stir about the introduction of e-cigarettes and unknown health issues that they may cause. For the mouth, e-cigarettes seem to have some positives and negatives. It is a better option than regular tobacco cigarettes, but worse than not smoking altogether. Here are a few of the effects of e-cigarettes on the mouth.

Unfortunately, research on e-cigarettes is still very minimal. Because they are a new product, research that can space several decades is still unavailable. However, there are several chemicals and clues that help determine what e-cigarettes can do to the teeth.

Just like any cigarette, the main purpose of an e-cigarette is to inhale nicotine. Studies have shown that nicotine can slow down the production of saliva in the mouth. The more nicotine you intake, the less saliva the body is able to produce. Saliva is a main deterrent to harmful bacteria and food particles in the mouth. Low saliva levels can cause quicker tooth decay, sore gums, and eventually a loosening of the teeth. One positive of smoking e-cigarettes verses normal cigarettes is that you can control the amount of nicotine the e-cigarette will release into the body. This will slow down the eventual effect of lowered saliva levels, at least.

Another effect of nicotine in an e-cigarette or a tobacco cigarette is it acts as a vasoconstrictor, which prohibits blood flow to the mouth. This results in a fewer number of white blood cells capable of fending off infections and bacteria that harm your gums. Fewer red blood cells are also sent to your mouth tissues, which lead to faster deterioration of the tissue and your teeth.

Another concern for e-cigarettes is that they contain diethylene glycol, a highly toxic substance. However, at the current point in research, scientists have not determined how much of the substance is needed to be considered harmful to the body, especially seeing e-cigarettes use a very low amount.

Dental hygienists should continue to support tobacco cessation through evidence-based methods, such as counseling and medications. The American Dental Hygienists’ Association’s (ADHA) “Ask, Advise, Refer” program is a national tobacco intervention initiative designed to promote cessation by dental hygienists. Available at askadviserefer.org, this program follows the most successful steps to aid patients in quitting smoking, including: an in-depth presentation on the effects of tobacco and nicotine; step-by-step guide on questioning smokers; tips on advising them of why quitting is recommended; specific referrals to local quit lines; and options for Web-based cessation programs. Also, a variety of in-office handouts and reference sheets is available for immediate download or by request from the ADHA website for clinicians.

The “Ask, Advise, Refer” program recommends offering some type of smoking cessation medication in addition to a behavioral program. One option is a traditional nicotine replacement therapy, or pharmacotherapy. FDA-approved traditional nicotine replacement therapy products include gum, lozenges, transdermal patches, nasal sprays, and oral inhalers. There are several success stories of individuals sucking on hard candy day after day. Unfortunately this may cause cavities, but if this can stop someone from using tobacco products then it is a success. Bupropion SR and varenicline are medications used to aid in cessation.

E-cigarettes have not been evaluated by the United States Food and Drug Administration (FDA), and the levels of nicotine or other chemicals they contain are unknown. The FDA is concerned that e-cigarettes are sold to young people and do not contain “health warnings comparable to FDAapproved nicotine replacement products or conventional cigarettes.” The administration is developing a strategy to regulate this emerging class of products.

Conclusion

In response to the decreasing number of adult cigarette smokers, the tobacco industry is trying to attract young people with “healthier” tobacco products in hopes of expanding the market. None of these products is free of carcinogens, and most still contain enough nicotine to pose an addiction risk. All of them increase users’ risk of oral cancer.

The challenge for dental professionals is to identify users of these products as they may lack the typical signs of tobacco use, such as tobacco stains and odor, and the appearance of tissue changes in unusual areas, such as under the upper lip. Clinicians can play a critical role in educating patients about the nicotine content and potential harmful effects of these new tobacco products. Not only can dental professionals provide cessation support or referral for counseling, but they can also help prevent nicotine addiction in the first place.

Electronic cigarettes are also known as ENDS (electronic nicotine delivery system), electronic cigarettes, or E-cigs. “Electronic cigarettes are designed to look like cigarettes, right down to the glowing tip. When the smoker puffs on it, the system delivers a mist of liquid, flavorings, and nicotine that looks something like smoke. The smoker inhales it like cigarette smoke, and the nicotine is absorbed into the lungs. The e-cigarette is usually sold as a way for a smoker to get nicotine in places where smoking is not allowed.” (www.cancer.org) When people use ENDS it is sometimes called vaping

E-cigs have a vaporization system, rechargeable batteries, controls and areas to refill the liquid for vaporization. The ENDS can contain between 6mg to over 100 mg of nicotine. Nicotine can be lethal in large amounts, 0.5-1.0 mg per kj of weight of the person. Because the products contain nicotine they can cause dependence and addiction. The chemicals used in the liquid for vaporization is not fully known. The products are not labeled or stated on the bottles.

Electronic cigarettes are on the rise throughout the world and in the United States. Here are some “commonly reported reasons for use: to quit smoking, to avoid relapse, to reduce urge to smoke, or as a perceived lower-risk alternative to smoking. Few studies, however, have explored whether electronic cigarettes (e-cigarettes) deliver measurable levels of nicotine to the blood. ” (Carcoran O., Dawkins L, 2013) This means that without measurable levels of nicotine in the blood it may not be an effective tool to quit smoking.

According to the US Centers for Disease Control and Prevention (CDC) the percentage of highschool and middle school students who have used electronic cigarettes has doubled from 2011 to 2012. Highschool increased from 4.7% in 2011 to 10% in 2012 and middle school increased from 1.4% to 2.7%. The National Youth Tobacco Study found that by 2012 more than 1.78 million middle and high school students in the US had tried e-cigarettes. (CDC, 2013)

“ENDS use is expanding rapidly despite experts’ concerns about safety, dual use and possible ‘gateway’ effects. More research is needed on effective public health messages, perceived health risks, validity of self-reports of smoking cessation and the use of different kinds of ENDS.” (Pepper JK, Brewer NT http://www.ncbi.nlm.nih.gov/pubmed/24259045) This statement is from a study completed in 2013. It is saying that even though experts are worried that it ENDS may not be safe and can lead to drug abuse of other substances the sales of E-cigs are increasing.

“The primary concern is whether e-cigarettes have the capability of introducing nonsmoking youth to cigarette smoking,” said Thomas J. Glynn, PhD, American Cancer Society’s director of cancer science and trends and international cancer control. “Will we have new cigarette smokers out of this? A very clear message is that we are very much in need of FDA (US Food and Drug Administration) regulations that will limit access to e-cigarettes to youth.”(Simon, 2013)

Acting through the Family Prevention and Tobacco Control Act of 2009 the FDA is working on creating regulations for the ENDS products. The FDA will require that electronic cigarettes label what is in the product, and how they can market and sell the ENDS. A few states have set regulations on selling and promoting e-cigarettes to ages 18 and younger, however, it is not illegal to sell ENDS to youth in most states. (Simon 2013) The producers of e-cigs are marketing to children, creating products that are meant to taste like candy.

Are Electronic Cigarettes Safe?

“The safety of ENDS has not been scientifically demonstrated.

The potential risks they pose for the health of users remain undetermined. Furthermore, scientific testing indicates that the products vary widely in the amount of nicotine and other chemicals they deliver and there is no way for consumers to find out what is actually delivered by the product they have purchased.

Most ENDS contain large concentrations of propylene glycol, which is a known irritant when inhaled. The testing of some of these products also suggests the presence of other toxic chemicals, aside from nicotine. In addition, use of these products -when they contain nicotine can pose a risk for nicotine poisoning (i.e. if a child of 30 Kilos of weight swallows the contents of a nicotine cartridge of 24 mg this could cause acute nicotine poisoning that most likely would cause its death) and a risk for addiction to nonsmokers of tobacco products. Nicotine, either inhaled, ingested or in direct contact with the skin, can be particularly hazardous to the health and safety of certain segments of the population, such as children, young people, pregnant women, nursing mothers, people with heart conditions and the elderly. ENDS and their nicotine cartridges and refill accessories must be kept out of the reach of young children at all times in view of the risk of choking or nicotine poisoning.

As ENDS do not generate the smoke that is associated with the combustion of tobacco, their use is commonly believed by consumers to be safer than smoking tobacco. This illusive ‘safety’ of ENDS can be enticing to consumers; however, the chemicals used in electronic cigarettes have not been fully disclosed, and there are no adequate data on their emissions.”

A study done by the FDA found cancer-causing substances in half the e-cigarette samples tested. Other impurities were also found, including one sample with diethylene glycol, a toxic ingredient found in antifreeze.

Dr. Thomas J. Glynn MA, MS, PhD, who is the director of Cancer Science and Trends and director of International Cancer Control for the American Cancer Society from the American Cancer Society created list of reasons why people favor e-cigarettes and why they oppose to their use.

Those who favor e-cigarettes list as benefits:

Their ability to deliver nicotine to the user without many of the other 7,000+ chemicals in a regular, burned cigarette;

Their absence of secondhand cigarette smoke;

Their resemblance to regular cigarettes, which provide the tactile and visual sensations – holding them in a certain way, a glowing tip, blowing smoke, etc. – that many cigarette smokers have become used to, or even psychologically dependent upon; and

Their potential for aiding cigarette smokers to who wish to quit to do so.

Those with concerns about e-cigarettes warn of:

Lack of scientific data about their safety. Simply put, e-cigarette users cannot be sure of what they are inhaling, since e-cigarettes have not been subjected to thorough, independent testing and, due to their manufacture by many different companies, there are no quality assurances in their production processes;

Lack of scientific data about their effectiveness as quit-smoking aides;

Lack of scientific data about the effect of secondhand vapor from e-cigarettes;

Lack of scientific data about whether the use of e-cigarettes encourages smokers who might have otherwise quit to continue smoking and only use e-cigarettes when they are in no-smoking environments; and

Lack of scientific data about whether youth may use e-cigarettes as an introduction to smoking regular cigarettes.

In the end one can clearly see the controversy over wether or not ENDS are good or bad.

Can I use ENDS to help me quit smoking?

“The efficacy of ENDS for helping people to quit smoking has not been scientifically demonstrated.

ENDS are often touted as tobacco replacements, smoking alternatives or smoking cessation aids. But we know that for smoking cessation products to be most effectively and safely used, they need to be used according to instructions developed for each product through scientific testing. There are no scientifically proven instructions for using ENDS as replacements or to quit smoking. The implied health benefits associated with these claims are unsubstantiated or may be based on inaccurate or misleading information. When ENDS are used as cessation aids, they are intended to deliver nicotine directly to the lungs. None of the approved, regulated cessation aids, such as nicotine patches and chewing-gum, delivers nicotine to the lungs. Therefore, the biological mechanism by which smoking cessation might be achieved by delivery of nicotine to the lungs and its effects are unknown. Delivery to the lung might be dangerous. Therefore, independently of the effects of nicotine, it is of global importance to study lung delivery scientifically.

The dose of delivered nicotine is also unknown. It is suspected that the delivered dose varies notably by product, which contain nicotine in various quantities and concentrations.”

An article found on the US National Library of MedicineNational Institutes of Health looked at how ENDS awareness increased from 16% to 58% from 2009 to 2011, and use increased from 1% to 6%. The article included data gathered from 49 other studies. The majority of users were current or former smokers. Many users found ENDS satisfying, and some engaged in dual use of ENDS and other tobacco.

No longitudinal studies examined whether ENDS serve as ‘gateways’ to future tobacco use. Meaning no studies have been completed that extend long periods of time. Some longitudinal studies are decades of gathered data. ENDS are a new product. There is no way to tell the long term effects of electronic cigarettes on the human body until one of these studies is completed. Self-reported survey data has been completed. Meaning people using the product filled out a questionnaire which includes their feelings and beliefs. These studies have validity problems. Prospective trials and self-reported surveys suggest that ENDS might help cigarette smokers quit, but no randomized controlled trials with probability samples compared ENDS with other cessation(quitting smoking) tools. Randomized controlled trials are the only reliable research worthy of trusting. (Pepper JK, Brewer NT http://www.ncbi.nlm.nih.gov/pubmed/24259045)

The World Health Organization states “Until such time as a given ENDS is deemed safe and effective and of acceptable quality by a competent national regulatory body, consumers should be strongly advised not to use any of these products, including electronic cigarettes.”

In conclusion reliable, independent, randomized controlled research needs to be conducted to solidify the pros and cons of electronic cigarettes. There is simply not enough information as to whether vaping is safe to use or a good tool to decrease or end smoking. Our public health choices and policies need to be decided upon fact. As for my health and the health of our patients I will wait or advise a patient to wait to use an electronic cigarette.